Stuck in the Medicaid gap in Idaho

By By AUDREY DUTTONMonday January 6, 2014 11:15 AM

BOISE, Idaho (AP) — Amy Workman and her 12-year-old son spent the holidays stuffing their Coeur d'Alene home into a moving truck. They gave away some furniture. They gave a neighbor their Christmas tree.

A few days after Christmas, the mother of three and her youngest son hit the road for Oregon. They headed west in search of health insurance.

Workman is one of the estimated 54,780 adults in Idaho who fall into the so-called Medicaid gap — a health insurance no-man's-land being created this year in Idaho and 24 other states where lawmakers decided not to expand Medicaid programs.

"It's not right," Workman said. "They're ignoring that people are falling through the cracks."

The 2010 Affordable Care Act ordered states to offer Medicaid coverage starting Jan. 1 for those between the poverty line and middle class. People making less than 1.38 times the federal poverty level — about $21,400 for a household like Workman's, using this year's guidelines — were to receive coverage. The federal government would subsidize insurance premiums for people who make up to four times the poverty line — a maximum of $62,040 for a household like Workman's.

In Idaho, the Medicaid program is open to impoverished children, people with disabilities and a few other groups of people. Adults can qualify if they're parents making less than $2,800 a year for a household the size of Workman's. The expansion would have added tens of thousands of adults to Idaho Medicaid.

But a U.S. Supreme Court ruling turned that plan upside down. The court said in 2012 that states have the power to choose whether they want a Medicaid expansion.

Idaho has opted out so far, and Gov. Butch Otter and members of the Legislature have made comments to suggest that they don't foresee an expansion bill passing this year.

That means Workman and parents like her, who make between $2,800 and $15,510 a year, fall into the Medicaid gap. (For single, childless adults, the threshold is lower.)

Those people basically have three options: Go without insurance, pay full price for a plan, or move to a state that opted in.

There are two sides to the Medicaid expansion debate — and an election this year is expected to make lawmakers reluctant to take up a vote on a bill.

Giving Medicaid to low-income adults would make almost irrelevant a catastrophic-medical program that costs Idaho taxpayers tens of millions of dollars a year; the savings are estimated to be as high as $1 billion over the next 10 years.

It would spare some employers the expense of insuring their lowest-wage employees or paying fines for not covering them. And it would mean Idaho reaps a benefit from the money its taxpayers will contribute this year to support Medicaid expansions nationally.

But opponents and skeptics of Medicaid expansion offer their own arguments:

- What if the federal government doesn't keep its end of the bargain — paying 90 percent to 100 percent of the costs for new enrollees — and leaves it up to states to pay for a wave of new Medicaid patients?

- Idaho's Medicaid program already costs about $2 billion a year, and the bill is rising. One-quarter of that money comes from state general funds. Most of the rest comes from federal coffers.

- Idaho could revamp its Medicaid program before adding people to it. Otter likes this option, and the Idaho Association of Commerce and Industry asked him to consider how to reform the program to pay for high-quality, high-value medical care instead of paying by the hour or by the vial, as it does now.

- They don't like the Affordable Care Act in general and don't want Idaho taking part in it.

Workman's last job, as a home-care aide for a special-needs child, did not offer health insurance.

But after injuring herself at work a year ago, she needed physical therapy, she said. She was denied workers' compensation benefits to cover prolonged therapy — a decision she is appealing — and started paying out of pocket to see doctors. She estimates she has racked up $8,000 in medical bills in the past six months. She has paid $500 of them.

"I went to apply for Obamacare," she said. She tried signing up for a plan from Your Health Idaho, the state's exchange. After three failed attempts at enrolling through the website, Workman went to an agent.

The income screening process didn't count child support or a workers' compensation check, "so I basically had zero income," she said. That meant she qualified for Idaho's zero-income Medicaid program.

At least, that's how it seemed — until she tried to sign up for Medicaid and learned that child support money and workers' comp pushed her over the line for eligibility.

"I have probably about $12 in my (bank) account," Workman said before leaving for Oregon. "I have to do something proactive for myself, or I'm not going to be able to put a roof over my son's head. ... I want to be better so my son can look up to me if I'm working."

During her first week in Oregon, Workman scoped out some apartments.

But before that, she applied for its Medicaid program, and hoped to hear some good news once her application was processed.

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